Records Reveal State Workers' Mistakes In Pregnant Teen's Suicide

Child-protection personnel failed to immediately start resuscitation efforts after a pregnant 16-year-old was found hanging in her room at the Solnit psychiatric center in Middletown on June 28, documents obtained by The Courant reveal. (File Photo)

Child protection personnel failed to immediately start resuscitation efforts after a pregnant 16-year-old was found hanging in her room at the Solnit psychiatric center for children in Middletown on June 28, and failed to immediately call for emergency medical technicians to respond, inspection documents obtained by The Courant on Thursday reveal.

The report states that Department of Children and Families staff members were routinely using an 11-digit phone number when calling for emergency services and had only recently “been permitted to call 911 if they do not remember the 11-digit number,” the public health inspection records state.

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The teen’s suicide led to a finding that DCF was placing patients in “immediate jeopardy.”

Inspectors found that a DCF staff member did not conduct the required face-to-face check of the teen during the 8:30 p.m. observation period. These checks were repeated every 15 minutes. Instead, the staff member opted not to enter the room, but “visualized [the teen] through the window in the door, moving back and forth in the closet area,” according to the report from the state Department of Public Health.

Ten minutes later, at 8:40 p.m., the staff member returned to the room to escort the teen to a pizza party and found her hanging. The worker “screamed for assistance” but “did not remove the resident from her hanging position, nor were emergency resuscitation efforts immediately initiated,” the inspection documents state. A second worker responded to the cry for help “… and started chest compressions immediately.”

In addition, a supervisor was called, “rather than the EMS system as problems were noted with the communication system earlier,” the report states.

After a nurse explained to the inspectors that staff members had relied on an 11-digit number and recently were given permission to use 911, she added that “time was wasted and the unit could have [taken action] more quickly and should have called the emergency number themselves.”

The teen had been scheduled to leave the Albert J. Solnit Center — South Campus on the following morning, June 29. Inspectors, quoting from patient files, said the teen “was having reservations” about her foster placement.

Inspectors also noted that DCF personnel had failed to remove a purse strap from another suicidal patient, and had failed to prevent another patient from obtaining a razor from a pencil sharpener, which the patient had used to cut him or herself repeatedly. Inspectors said that staff members were not always increasing the frequency of checks on patients in response to a change in a patient’s behavior or mood.

The public health agency inspected Solnit on 12 separate days between June 29 and Wednesday. It was on Wednesday that the department accepted DCF’s plan of correction, confirmed it had been put in place, and lifted the designation of immediate jeopardy.

The Courant has reported that DCF has added random checks to the 15-minute observation periods, added nurses, required that psychiatrists review the risk assessments that the nurses do on every patient, and installed oxygen tanks, suction devices and surveillance cameras in every patient unit.

The documents obtained Thursday show that staff members have received training in updated emergency medical care procedures, and that each staff person has been given an “emergency numbers” card “to carry on their person.” The agency has also given staff members refresher training in “when to place a youth on continuous observation due to change in mental status or behavior,” DCF reported.

In March, three months before the teen’s suicide, the Solnit center had been placed on immediate jeopardy status following two suicide attempts by patients. The designation had been lifted later in the spring.